CH 14- Medication Safety and Error Prevention

Five Rights of Medication Safety

Includes right patient, medication, dose, route, and time

Alert the pharmacist

the first step a pharmacy technician should take upon detecting a medication error

FDA

oversees MedWatch

IV oxytocin

the ISMP consider this to be a high-alert medication

Risk evaluation and mitigation strategy

REMS is a strategy used to manage known and potential serious risks of a drug or biologic product. The FDA requires REMS to ensure that the benefits of a drug outweigh its risks

Ointment

a hydrophobic product such as petroleum jelly.

Prescribing errors

Mistakes in prescribing medication, e.g., incorrect strength or illegible handwriting

Solvent

The water portion of saline solution

Drug manufacturers

may mass produce medications

ADR

Adverse drug reaction

Dispensing errors

Mistakes in dispensing medication, e.g., incorrect interpretation or calculations

Administration errors

Mistakes in administering medication, e.g., placing ear medications in the eye

Stress as a cause of errors

Increased demand for services leading to more error occurrence

Pharmacy Technician Educator's Council

PTEC

Noise as a cause of errors

Causes distractions affecting concentration

USP <797>

addresses the problem of contamination of any type of sterile product.

MERP

used in error reporting

ASHP

The organization that accredits pharmacy technician programs

Multitasking as a cause of errors

Engaging in multiple tasks simultaneously

MedWatch

a program established by the FDA for reporting drug and medical product safety alerts and label changes. The program also provides a voluntary adverse-event reporting system for medications, medical products, and devices.

Tall-man lettering

a strategy to reduce errors would label bupropion and buspirone as buPROPion and busPIRone on the pharmacy shelf

national Vaccine Error Reporting Program (ISMP VERP)

Collects information on vaccine errors.

LASA drugs

Look-alike, sound-alike drugs leading to incorrect interpretation and utilization

Drug labeling

Using color coding, tall man lettering, and boldface to prevent errors

Standardized graphics that represent how to take, when to take, and how to store a medication

Pictograms

Excessive workload as a cause of errors

Handling hundreds of prescriptions daily without breaks

Warfarin interactions

Given to prevent clots; interactions with aspirin, phenytoin, quinolones, etc.

Open error reporting

Essential for identifying causes and setting safeguards to prevent future errors

Health care-associated infections (HAIs)

Infections related to hospital or home health care errors

Age-Related Errors

Older patients prone to polypharmacy and drug-food interactions

Parenteral Errors

Quickly effective errors, e.g., confusion between Hep-Lock and heparin solutions

Sustained-Released Dosage Form Errors

Giving SR medication instead of regular dose leading to adverse effects

Necessity of Reporting Errors

Essential for identifying causes and implementing changes to reduce errors

e-Prescribing

Prescriptions sent directly to pharmacy from computer or mobile device

Strategies to Reduce Medication Errors

Dispensing vinca alkaloids in minibags, using weekly dosage regimen, patient education, metric units, and oral syringes

Common Pharmacy Technology

Includes barcodes, Robot-Rx machines, and automated dispensing systems

Patient Dose-Specific Orders

TJC requires prepacking liquid doses in oral syringes with patient-specific labeling

United States Pharmacopeia <797> Regulations

Addresses contamination of sterile products; emphasizes error reduction and thorough prescription checking

Medication Reconciliation

Process of identifying up-to-date list of patient's medications for proper administration

Quality Assurance Practices and Risk Management

Includes double-counting narcotics, inspecting fire extinguishers, and using technology

Training and Education

Emphasizes certification, continuing education, and triple-checking prescriptions